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Q: What is Medicaid?A: The Medicaid Program provides medical benefits to New Yorkers who cannot afford to pay for medical care. Though the federal government establishes general guidelines for the Medicaid program, each state establishes its own program, including eligibility criteria. The New York State Medicaid program is funded through federal, state and county funds. It represents a very large portion of New York State’s annual budget – amounting to over $50 billion per year.

A: The New York State Medicaid Fraud Control Unit (“MFCU”) is a division of the Office of the New York State Attorney General and has statewide authority to investigate and prosecute all violations of applicable state laws regarding fraud in the provision of medical assistance under the Medicaid program. Federal regulations require States to create Medicaid fraud control units to combat fraud, waste, and abuse in the Medicaid Program. In doing so, the MFCU has wide-ranging investigative powers in healthcare settings.

A: : The NYS MFCU's mission has two distinct and complementary parts: (1) to investigate and prosecute health care providers and Medicaid administrators who defraud the Medicaid program and (2) to investigate and prosecute those who abuse, neglect or mistreat residents in facilities paid to provide nursing and/or personal care services to one or more unrelated adults.

In fact, the MFCU's jurisdiction extends to all such facilities — regardless of whether the patient is a recipient of Medicaid funding. When Congress created the MFCUs in 1977, it did so not only because of the evidence of massive fraud in the Medicaid program, but also because the horrendous examples of nursing home abuse and victimization. The MFCU has authority to hold accountable individuals or corporations who defraud the Medicaid program or abuse residents of health care facilities through both criminal prosecution and/or civil litigation. To prevent fraud, the MFCU makes regulatory recommendations to the New York State Department of Health, which administers the Medicaid program, and the Office of the Attorney General submits legislative proposals to the state legislature. The MFCU also makes referrals to New York State licensing agencies so that they can sanction, when appropriate, licensed health care providers.

Q: What do MFCU's various regional offices and specialized divisions do?

A: The MFCU has seven offices located in Albany, Buffalo, Hauppauge, New York City, Pearl River, Rochester, and Syracuse, and other specialized legal and investigative sub-divisions: the Civil Enforcement Division (based primarily in New York City, Syracuse, and Pearl River); the New York City Patient Protection Section; and the Electronic Investigative Support Group (based in Rensselaer). The Unit also includes a Finance Department, which is responsible for the administration of financial recoveries and statewide purchasing, and Personnel Administration.)

The MFCU's regional offices handle criminal fraud, patient abuse and neglect cases, and local civil enforcement actions. Due to the number of residential care facilities in New York City, the Unit has a special Patient Protection Section that focuses exclusively on patient abuse and neglect cases in the five boroughs.

The Civil Enforcement Division handles complex civil fraud investigations using authority under the New York False Claims Act, Social Services Law § 145-b, and the Executive Law, and initiates asset forfeiture actions and other actions involving civil remedies related to prosecutions. MFCU joins and takes a leading role in nationwide task forces investigating corporations operating in states across the country and investigates and, when appropriate, intervenes in qui tam (whistleblower) civil actions. The Electronic Investigative Support Group is responsible for housing, organizing and maintaining state Medicaid claims data required for investigations, conducting complex data analysis, and managing the Unit's computer network.

A: Members of the public - including Medicaid recipients and whistleblowers - are our most important source of cases, as they often identify schemes that have not yet been discovered by investigative agencies. The MFCU also receives referrals from a variety of local, state, and federal agencies including the New York State Department of Health, the New York State Office of the Medicaid Inspector General, the Office of the State Comptroller, and the United States Department of Health and Human Services. Additionally, the Unit frequently generates new cases as it investigates currently existing cases.

A: Due to the amount of money expended by the Medicaid Program, the methods for theft of that money are limited only by the imagination of the criminal. However, it is common to see schemes deploying the following techniques:

Operating Medicaid “mills” – creating businesses for the main purpose of generating money by billing the Medicaid program regardless of the actual medical need of the patients in the community

Billing for medically unnecessary services

Selling prescriptions or access to prescription drugs for the purpose of abuse or misuse

Double-billing (billing both Medicaid and a private insurance company or the recipient directly, or multiple providers billing Medicaid for the same recipient for the same procedure)

Kickbacks -- making financial arrangements between providers involving some financial benefit in return for another provider prescribing or using their products or services, which frequently results in unnecessary treatment

Falsely inflating reimbursement rates for large institutions such as nursing homes, hospitals or clinics by falsifying financial reports on which the rates are set

Employing healthcare professionals or other staffers who have been previously barred from government healthcare programs due to prior fraud or other abusive practices

Cheating patients by demanding cash payments on the side for services insured by Medicaid

Billing for services not rendered or “upcoding” by billing Medicaid for more expensive procedures than those that are actually performed

Overbilling for services paid by the hour – such as home health care – by submitting or approving false time records

Q: Does the MFCU investigate and/or prosecute Medicaid recipient fraud?A: The MFCU investigates and/or prosecutes Medicaid recipient fraud only in conjunction with provider fraud investigations and prosecutions. The New York State Office of the Welfare Inspector General (http://www.owig.ny.gov/) and local district attorneys have jurisdiction to prosecute individuals who filed false applications in order to receive Medicaid benefits.

Q: Does the MFCU handle questions relating to Medicaid benefits?A: No. If you have questions regarding Medicaid eligibility or benefits, you should contact your local department of social services. You can access the statewide list of these departments at www.nyhealth.gov/health_care/medicaid/ldss.htm.

Q: Does the MFCU investigate and/or prosecute Medicare fraud? A: Medicare is a federally funded health insurance program for individuals age 65 or older, individuals under age 65 with certain disabilities, and individuals of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). The MFCU has jurisdiction to investigate Medicare fraud only with the consent of the Office of the Inspector General of the United States Department of Health and Human Services and only if the case as a whole is primarily related to Medicaid. To report Medicare fraud, contact: http://www.medicare.gov/forms-help-and-resources/report-fraud-and-abuse/report-fraud/reporting-fraud.html

Q: How do I report suspected Medicaid provider fraud?A: Call the Office of the New York State Attorney General's Medicaid Fraud Control Unit at (800) 771-7755, orfile a report on-line by clicking here,

Q: How do I file a complaint about the abuse and/or neglect of a patient in a residential care facility?

A: Call the Office of the New York State Attorney General’s Medicaid Fraud Control Unit at (800) 771-7755, the New York State Department of Health at (888) 201-4563, or file a complaint on-line. In case of an emergency, call 911.